<div id="receptionInfoDiv">
	<h3><a style='background-color: #EEE;' href="#"><span style="text-transform: uppercase; font-weight: bold;">{translate}Emergency information{/translate}</span></a></h3>
	<div>
        <table cellspacing='0' cellpadding='0' class='grid' style='width: 100%'>
            <tr>
                <td class="form_label" style='width:125px'>{translate}Patient name{/translate}</td>
                <td class="form_input"><input id="personName" name="person[name]" type="text" value="{$person->getName()}" style="width: 160px;"/></td>
                <td class="form_label" style='width:100px'>{translate}Gender{/translate} *</td>
                <td class="form_input">
                    {if $person->getGender()=='male'}
                     <input id='genderMaleRdb' type="radio" name="person[gender]" value="male" checked="checked"/><span class='label'>{translate}Male{/translate}</span>&nbsp;
                     <input id='genderFemaleRdb' type="radio" name="person[gender]" value="female"/><span class='label'>{translate}Female{/translate}</span>
                    {elseif $person->getGender()=='female'}  
                     <input id='genderMaleRdb' type="radio" name="person[gender]" value="male"/><span class='label'>{translate}Male{/translate}</span>&nbsp;
                     <input id='genderFemaleRdb' type="radio" name="person[gender]" value="female" checked="checked"/><span class='label'>{translate}Female{/translate}</span>
                    {else}
                     <input id='genderMaleRdb' type="radio" name="person[gender]" value="male"/><span class='label'>{translate}Male{/translate}</span>&nbsp;
                     <input id='genderFemaleRdb' type="radio" name="person[gender]" value="female"/><span class='label'>{translate}Female{/translate}</span>
                    {/if}                                                                              
                </td>
                <td class="form_label" style='width:125px'>{translate}Check-in time{/translate} *</td>
                <td class="form_input" style='width:200px'>
                    <input name="checkIn_{$datePart_0}" id="checkIn_{$datePart_0}" type="text" value="{$checkInDate.0}" style="width: 21px;"><span class="label">-</span><input name="checkIn_{$datePart_1}" id="checkIn_{$datePart_1}" type="text" value="{$checkInDate.1}" style="width: 21px;"><span class="label">-</span><input name="checkIn_{$datePart_2}" id="checkIn_{$datePart_2}" type="text" value="{$checkInDate.2}" style="width: 40px;"><span class="label">&nbsp;&nbsp;</span><input name="checkInTimeTxt" id="checkInTimeTxt" type="text" value="{$checkInTime}" style="width: 40px;"/>
                    <br/>
                    <span class="label" style="width: 21px; color: #AAA;">({$datePart_0}-{$datePart_1}-{$datePart_2} hh:mm)</span>
                </td>
            </tr>
            <tr>
                <td class="form_label">{translate}Check-in reason{/translate}</td>
                <td class="form_input" colspan='2'><input type="text" name="reasonTxt" id="reasonTxt" style="width: 200px;" value="{$reception->getCheckInReason()}"/></td>
                <td class="form_label">{translate}Injury description{/translate}</td>
                <td class="form_input" colspan="2"><textarea name="injuryDescriptionTxt" id="injuryDescriptionTxt" rows="1" style="width: 200px;">{$reception->getInjuryDescription()}</textarea></td>
            </tr>
            <tr>
                <td class="form_label">{translate}Injury level{/translate}</td>
                <td class="form_input" colspan="2">
                    {html_options name='injuryLevelRdb' options=$injuryLevelList selected=$reception->getInjuryLevel()}
                </td>
                <td class="form_label">{translate}Transport{/translate}</td>
                <td class="form_input" colspan="2">
                    {html_options name='transportRdb' options=$transportList selected=$reception->getTransport()}
                </td>
            </tr>
            <tr>
            </tr>
            <tr>
                <td class="form_label">{translate}Original place{/translate}</td>
                <td class="form_input" colspan="2">
                    <input type="text" name="orignalPlaceTxt" style="width: 200px;" value="{$reception->getOriginalPlace()}">
                </td>
                <td class="form_label">{translate}Original diagnosis{/translate}</td>
                <td class="form_input" colspan="2"><textarea name="preDiagnosisTxt" id="preDiagnosisTxt" rows="1" style="width: 200px;">{$reception->getOriginalDiagnosis()}</textarea></td>
            </tr>
            <tr>
            	<td class='form_label'>{translate}Allergy{/translate}
            	</td>
            	<td colspan='5'>
	            	<table cellpadding="0" cellspacing="0" style="width:100%">
	            	<tr>
	            		<td style='width:135px'>
	            			{if $allergy == 0}
	            			<input type='checkbox' id='allergyChk' name='allgergyChk' onclick='return checkAllergy()'/>
	            			{else}
	            			<input type='checkbox' id='allergyChk' name='allgergyChk' checked='checked' onclick='return checkAllergy()'/>
	            			{/if}
            			</td>
	            		<td class='form_label'>{translate}General Allergy{/translate}</td>
	            		<td>
	            			{if $allergy == 0}
	            			<input type='text' id='generalAllergyTxt' name='generalAllergyTxt' style='width:160px' disabled='disabled' />
	            			{else}
	            			<input type='text' id='generalAllergyTxt' name='generalAllergyTxt' style='width:160px' value='{$generalAllergy}' />
	            			{/if}
	            		</td>
	            		<td class='form_label'>{translate}Drug Allergy{/translate}</td>
	            		<td style='width:200px'>
	            			{if $allergy == 0}
	            			<input type='text' id='drugAllergyTxt' name='drugAllergyTxt' style='width:160px' disabled='disabled' />
	            			{else}
	            			<input type='text' id='drugAllergyTxt' name='drugAllergyTxt' style='width:160px' value='{$drugAllergy}' />
	            			{/if}
	            		</td>
	           		</tr>
	           		</table>
            	</td>
            </tr>
            <tr>
                <td colspan="6"><span style="text-transform: uppercase; font-weight: bold;">{translate}Emergency aid giver's information{/translate}</span>
            </tr>
            <tr class='last'>
                <td class="form_label">{translate}Full name{/translate}</td>
                <td class="form_input"><input id="aiderNameTxt" name="aiderNameTxt" type="text" style="width: 160px;" value="{$reception->getAiderName()}"/></td>
                <td class="form_label">{translate}Phone number{/translate}</td>
                <td class="form_input"><input id="aiderPhoneTxt" name="aiderPhoneTxt" type="text" style="width: 160px;" value="{$reception->getAiderPhone()}"/></td>
                <td class="form_label">{translate}Address{/translate}</td>
                <td class="form_input"><textarea id="aiderAddressTxt" name="aiderAddressTxt" rows="1" style="width: 200px;">{$reception->getAiderAddress()}</textarea></td>
            </tr>
        </table>
    </div>
</div>